Cancer patients in Palliative Care: occurrences related to venipuncture and hypodermoclysis

Abstract Objective: to identify the occurrences related to peripheral venipuncture and hypodermoclysis among patients hospitalized in a general hospital and in an exclusive hospital institution for the care of patients in palliative cancer care. Method: an observational, descriptive and multicenter study. The consecutive and non-probabilistic sample consisted of 160 cancer patients hospitalized in Palliative Care. The outcome variable corresponded to the occurrences and complications related to each type of puncture. A questionnaire containing the sociodemographic and clinical variables and a structured script for monitoring and daily evaluation of the puncture were used. Descriptive statistics were employed for data analysis. Results: the occurrences related to venipuncture at a general hospital were blood soiling at catheter insertion (17.4%) and expired use period (15.8%), while at a specific service for the care of patients under palliative care they were expired use period (32%) followed by infiltration (18.9%). As for hypodermoclysis, there were two subcutaneous punctures with phlogistic signs (1.0%) at the general hospital and a hematoma at the catheter insertion site (0.5%). At the specific service for the care of patients under palliative care there were three subcutaneous punctures with phlogistic signs (5.7%). Conclusion: the number of occurrences related to peripheral venipuncture was higher than those related to hypodermoclysis.


Introduction
Palliative Care (PC) is mainly offered to people who are at the end of life without age restriction, who face intense health-related distress due to serious diseases.
The objective of PC is to offer active holistic care and improve the quality of life of patients, their families and their caregivers (1) .
Hospitalization of patients in PC is recurrent due to the need to control the signs and symptoms they present, required by the complications related to diagnosis and evolution of the disease. In such situations, it is necessary to obtain an access route for parenteral drug therapy (2) .
Thus, some technological options in the health area and in the development of PC therapy have been adopted, such as techniques and options for the administration of fluids and medications. Alternative routes need to be considered for this purpose, as patients in PC usually present difficulties and/or impossibility of oral administration of medications in the face of the symptoms presented (3)(4) .
The use of peripheral venous catheters (PVCs) for intravenous administration of medications and solutions has become an indispensable resource for care in the hospital environment (5) . However, a number of studies have documented high incidence of peripheral vascular trauma during PVC use, in addition to other complications, the most frequent being phlebitis, infection at the catheter insertion site, bacteremia and sepsis, reinforcing that use of such devices is not free from risks of complications (5)(6)(7)(8) .
Given the above, considering the profile of patients undergoing PC in whom fragility of the venous network often hinders or prevents puncture of a peripheral vein, it is necessary to consider other possible routes, one of which is puncturing the subcutaneous route, or hypodermoclysis.
The term hypodermoclysis refers to the subcutaneous (SC) infusion of isotonic fluids and/or medications (9) . It is a simpler procedure than peripheral venipuncture, safe and without serious complications.
However, the technique is still poorly disseminated and used in the clinical practice (2,10) .
Complications related to using the SC route are rare when proper use of the puncture technique, dilution and infusion of medications is adopted (11)(12) . In addition to that, use of the SC route is less costly and less invasive than using the intravenous route (11) .
However, it is worth noting that hypodermoclysis has different indications and its use should be carefully evaluated, taking into account the characteristics of the patient and the medications prescribed, among others (12-13) .
In the national scenario, publications on the complications related to hypodermoclysis when compared to peripheral venipuncture are restricted to review studies (4,14) .
In view of the above, the objective of this study was to identify the occurrences related to punctures among patients hospitalized in a general hospital and in an exclusive hospital institution for the care of patients in palliative cancer care.

Study design
An observational, descriptive and multicenter study.

Study locus
The study was conducted in two health services.

Period
The recruitment period took place between January 2019 and February 2020.

Population and sample
The sample was consecutive and non-probabilistic, consisting of 160 cancer patients hospitalized in Palliative www.eerp.usp.br/rlae 3 Bolela F, Lima R, Souza AC, Moreira MR, Lago AJO, Simino GPR, et al.
Care. The potential participants were identified by a daily active search in the inpatient units. The eligibility criteria were verified at that moment. The potential participants were invited to the research, which involved daily observation of the puncture (venous or subcutaneous) and evaluation of the patients' clinical conditions. In situations in which the patients did not present due clinical conditions to consent to participate in the study, their companions were responsible for doing so.

Selection criteria
The inclusion criteria were as follows: cancer  There were no follow-up losses of patients during the data collection period.

Data treatment and analysis
The data were structured in Microsoft Excel The clinical characteristics of the study participants are shown in Table 2.

Discussion
In this study, the number of female participants in both hospitalization loci was higher, corroborating other national and international studies (15)(16)(17)(18)(19)(20)(21) . Both in Brazil and in other developing countries, there is predominance of cancer in the female population, which is related to the high detection rates of gender-specific neoplasms such as cervical cancer (22) .
Predominance of aged patients was observed in the current study. In a study that aimed at characterizing the patients evaluated by the Palliative Care service of a    Table 4.
University Hospital in the Brazilian Southeast region, aged patients predominated in the population of interest (23) , as is also the case in some international studies (17)(18) . A survey that aimed at evaluating the quality of life of cancer patients in Palliative Care obtained younger participants in its study, diverging from the findings of the current research (20) . As in the current study, the authors identified that the most frequent marital status among the participants was married (52%) (23) . Another study that aimed at evaluating the health-related quality of life of cancer patients in Palliative Care and its association with sociodemographic and clinical aspects also obtained greater participation of married patients or in a consensual union (16) .  (15) . These authors report that the low schooling level associated with increasing age becomes a concern with regard to these people's ability to correctly understand diverse information, guidelines and recommendations related to health care in general (16) . prostate (13.5%), colon and rectum (10.9%), stomach (7.2%) and liver (6.3%). In women, the highest incidence values corresponded to breast cancer (24.2%), followed by colon and rectum (9.5%), lung (8.4%) and cervix (6.6%) (28) .
The data obtained in this study differ from those obtained with the same patient profile. In a study conducted in 2020, the authors identified that the most prevalent types of cancer in the population studied were gynecological (23.8%), gastrointestinal system (19.1%) and breast (14.3%) (20) .
In the current study, the main caregiver corresponded to a family member in both institutions. Family caregivers play an important role in the care of patients with advanced disease (29) . However, it is necessary to be aware of the emotional burden involved in the process of caring for a family member in Palliative Care, that is, it is necessary that Nursing professionals encourage family caregivers in the care duties and are aware of the identification and reduction of stressors to which they are susceptible (30) .
In both institutions participating in the study, the number of venipunctures performed was significantly higher than the subcutaneous punctures. This fact is similar to the findings of a study that aimed at analyzing the use of hypodermoclysis in cancer patients with criteria for PC in two public general hospitals from Belo Horizonte (2) . In addition, the authors mention that there was greater use of the subcutaneous route by the service that had a Palliative Care team.
Although performance of hypodermoclysis is guided by important advantages to the intravenous route, among them greater puncture ease and lower risk of serious complications, such intervention is still underused in the clinical practice (31) .
In HERP, the main purpose for obtaining a parenteral route was antibiotic therapy, followed by analgesia. At INCA, the main purpose was analgesia. These findings corroborate the results of another study that identified analgesia as the main purpose for parenteral access (24) .

Considering that a significant range of antibiotics is
incompatible with the subcutaneous route, the fact of observing a greater number of punctures in a service where the main purpose of the puncture was antibiotic therapy is plausible.
The literature points out that hospitalization of patients in Palliative Care is frequent due to the need to control unpleasant symptoms such as pain, nausea and vomiting, dyspnea and others, related to the underlying disease itself and its evolution, which exert an excessive impact on the patients' quality of life and, therefore, need to be managed properly (24) .  (34) . a rate similar to that of the current study (36) .
In view of such notes, it is observed that failures related to the use of venous catheters are common, and that the inconsistency found between what is recommended in the guidelines and the practice is real (34) .